Care Transitions and Peer Support for Hospital Readmission

Overseen By Rachel K Henesy, PhD

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: University of South Florida

Disqualifiers: Substance use, Suicidal, Psychotic, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: Unknown

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial aims to reduce unplanned hospital readmissions by testing two care strategies for older adults with chronic illnesses like heart disease, diabetes, or COPD. One group will receive the Care Transitions Intervention (CTI), another will receive CTI plus Peer Support, and a third will receive the usual post-discharge care. The trial focuses on African American and Latino/Hispanic seniors discharged home after a hospital stay. Ideal participants identify as African American or Latino/Hispanic, are over 60, and have a chronic illness without planned readmissions. The goal is to determine if these care strategies can improve health outcomes and reduce healthcare disparities. As an unphased trial, this study allows participants to contribute to research that could enhance care strategies and address healthcare disparities.

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications. It is best to discuss this with the trial coordinators or your healthcare provider.

Is there any evidence suggesting that this trial's treatments are likely to be safe?

Research shows that the Care Transitions Intervention (CTI) is generally safe for patients. Studies have found that CTI can reduce the likelihood of patients needing to return to the hospital soon after discharge. No major safety issues have been reported with CTI.

Detailed safety information on adding Peer Support (PS) to CTI is limited. However, combining CTI with PS aims to provide more comprehensive support, which could be beneficial. These methods are designed to ease the transition from hospital to home and enhance patient support. No evidence suggests that adding Peer Support introduces new safety risks.

Both CTI and Peer Support focus on improving care quality and reducing the chances of hospital readmission. While specific safety details for CTI with Peer Support remain incomplete, the primary goal is to enhance patient care without adding risks. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about this trial because it explores innovative ways to reduce hospital readmissions. The Care Transitions Intervention focuses on improving the discharge process by providing patients with personalized support, helping them navigate their post-hospital care more effectively. Adding peer support to this intervention means patients can connect with someone who has faced similar health challenges, offering emotional support and practical advice. This combined approach could enhance recovery and reduce the risk of returning to the hospital, making it a promising alternative to traditional discharge procedures.

What evidence suggests that this trial's treatments could be effective for reducing hospital readmissions among older adults?

Research has shown that the Care Transitions Intervention (CTI), which participants in one arm of this trial will receive, can reduce hospital readmissions. In one study, CTI lowered hospital returns within 30 days by 30% compared to regular care. Another study found that those who did not receive the intervention were 73% more likely to return to the hospital. Another arm of this trial will test adding Peer Support to CTI, aiming to enhance these outcomes, particularly for older adults from minority groups who have not benefited as much from CTI alone. Peer support is expected to make the program more culturally sensitive and effective. ^{6 7 8 9 10}

Who Is on the Research Team?

Amber M Gum, Phd

Principal Investigator

University of South Florida

Are You a Good Fit for This Trial?

This trial is for African American and Latino/Hispanic older adults aged 60+ with chronic illnesses like heart disease, diabetes, or COPD. Participants must be discharged from one of the three partner hospitals to their home without planned readmissions and have access to a phone. They should speak English or Spanish.

Inclusion Criteria

I am 60 years old or older.

Identify as African American or Latino/Hispanic (any race)

Are being discharged from one of our three hospital partners to home with no planned readmissions

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Care Transitions Intervention (CTI)

Participants receive the Care Transitions Intervention, a non-clinical coaching strategy that occurs in the hospital, home, and via telephone for 28 days post-discharge

4 weeks

Care Transitions Intervention and Peer Support (CTI + PS)

Participants receive the Care Transitions Intervention enhanced with peer support to improve outcomes among racial/ethnic minority older adults

4 weeks

Follow-up

Participants are monitored for unplanned hospital readmissions and secondary health outcomes at 30 days, 90 days, and 6 months

6 months

What Are the Treatments Tested in This Trial?

Interventions

• Care Transitions Intervention
• Care Transitions Intervention and Peer Support
• Usual Care

Trial Overview The study tests if adding peer support to the Care Transitions Intervention (CTI) reduces unplanned hospital readmissions among minority older adults compared to usual care alone. It measures outcomes at different times up to six months after discharge, including emergency visits and patient well-being.

How Is the Trial Designed?

Group I: Usual Care Experimental Treatment 1 Intervention

Patient participants in this arm will receive the usual discharge/transition care provided by the hospital.

Group II: Care Transitions Intervention Experimental Treatment 1 Intervention

Patient participants in this arm will receive the Care Transition Intervention.

Group III: Care Transition Intervention and Peer Support Experimental Treatment 1 Intervention

Patient participants in this arm will receive the Care Transition Intervention.

Who Is Running the Clinical Trial?

University of South Florida

Lead Sponsor

Trials

433

Recruited

198,000+

Tampa General Hospital

Collaborator

Trials

22

Recruited

4,400+

Lakeland Regional Health Medical Center

Collaborator

Trials

1

Recruited

480+

Patient-Centered Outcomes Research Institute

Collaborator

Trials

592

Recruited

27,110,000+

AdventHealth

Collaborator

Trials

118

Recruited

31,800+

Published Research Related to This Trial

A study involving 38 hospital-based professionals identified multiple hazards to medication safety for older adults during care transitions, highlighting issues such as complex dosing and knowledge gaps in medication management.

The research revealed that medication-related harms stem from both hospital work systems and challenges faced at home, emphasizing the need for improved communication and support for patients and caregivers post-discharge.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Understanding Hazards for Adverse Drug Events Among Older Adults After Hospital Discharge: Insights From Frontline Care Professionals. Xiao, Y., Smith, A., Abebe, E., et al.[2023]

The Modified Physician-PREPARED scale was validated as a reliable tool to measure outpatient physicians' perceptions of hospital discharge quality, based on a survey of 403 patients and a 76% response rate.

Higher scores on the scale were associated with better discharge planning and communication, particularly when outpatient physicians were involved in the discharge process and aware of community support services.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Discharge planning scale: community physicians' perspective. Graumlich, JF., Grimmer-Somers, K., Aldag, JC.[2015]

The Brief PREPARED (B-PREPARED) instrument, tested in a study of 460 patients, effectively measures how prepared patients feel for discharge from the hospital, showing good internal consistency and predictive validity.

Higher scores on the B-PREPARED scale correlate with better satisfaction regarding medication information and predict fewer emergency department visits after discharge, indicating its potential usefulness in improving discharge processes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Brief scale measuring patient preparedness for hospital discharge to home: Psychometric properties. Graumlich, JF., Novotny, NL., Aldag, JC.[2015]

A national study called Project ACHIEVE identified eight essential components of effective transitional care (TC) for vulnerable Medicare beneficiaries, including patient and caregiver engagement, medication management, and care continuity.

The study emphasizes that addressing all identified TC components is crucial for improving health outcomes and meeting the needs of patients and caregivers, highlighting the importance of a patient-centered approach in healthcare transitions.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Components of Comprehensive and Effective Transitional Care. Naylor, MD., Shaid, EC., Carpenter, D., et al.[2018]

Citations

1. pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov/21788540/

The care transitions intervention: translating from efficacy to ... The Care Transitions Intervention has reduced 30-day hospital readmissions by 30% in a randomized controlled trial in an integrated health system.

2. sciencedirect.com sciencedirect.com/science/article/abs/pii/S0020748925002676

Effects of the care transition intervention on hospital ... Also, hospital readmission in the control group was 73 % higher than the experimental group. The greatest effect of the intervention for quality ...

3. jamanetwork.com jamanetwork.com/journals/jamanetworkopen/fullarticle/2812390

Transitional Care Interventions From Hospital to ... These interventions were associated with between 18% and 55% reductions in hospital readmissions compared with usual care. High-complexity ...

4. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC6559370/

A Transition Care Coordinator Model Reduces Hospital ... In multivariable models, hospitalizations with TCC Care had significantly lower odds of readmission at 30 days (OR=0.512, 95% CI 0.392 to 0.668) and 90 days (OR ...

5. healthcatalyst.com healthcatalyst.com/learn/success-stories/reduce-hospital-readmission-rates-utmb

Care Transitions Improvements Reduces 30-Day All- ... RESULTS · 14.5 percent relative reduction in 30-day all-cause readmission rate. · $1.9 million in cost avoidance, the result of a reduction in 30-day all-cause ...

6. ncbi.nlm.nih.gov ncbi.nlm.nih.gov/books/NBK555516/

Care Transitions - Making Healthcare Safer III - NCBI The TCM intervention group had lower hospital readmission rates at 30 days (6/66) than the ASC (15/66, p<0.001) and resource nurse care (14/71, p=0.06) groups.

7. bmchealthservres.biomedcentral.com bmchealthservres.biomedcentral.com/articles/10.1186/s12913-024-11047-3

Quality of care transition, patient safety incidents, and patients ... This study aimed to investigate the associations between the quality and safety of the discharge process, patient safety incidents, and health-related outcomes ...

8. jamanetwork.com jamanetwork.com/journals/jamainternalmedicine/fullarticle/2804119

Effects of a Multimodal Transitional Care Intervention in ... A transitional care intervention targeting higher-risk medical patients reduce the risk of 30-day unplanned hospital readmission or death.

9. psnet.ahrq.gov psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge

Readmissions and Adverse Events After Discharge | PSNet A classic study found that nearly 20% of patients experience adverse events within 3 weeks of discharge, nearly three-quarters of which could have been ...

10. onlinelibrary.wiley.com onlinelibrary.wiley.com/doi/10.1111/jan.15579

The effect of transitions intervention to ensure patient safety ... The intervention significantly decreased 30 days readmission rate (p ˂ 0.01) but did not decrease the number of acute care visits or increase ...